Pharmacy

Considering EmblemHealth?

Glossary

An evaluative process in which a healthcare organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

Active Contract

A member that currently has coverage with EmblemHealth

Actual Charge

The amount a physician or other practitioner actually bills a patient for a medical service or procedure.

Acupuncture

A traditional Chinese medical practice of insertion of fine needles into specific exterior body locations to relieve pain, to induce surgical anesthesia, and for therapeutic purposes.

Acute Illness

A physical condition or illness that begins abruptly and requires medical care or restricted activity for a short period of time (usually 3 months or less).

Adjudication

The process by which a claim is paid or denied based on eligibility and contract determination.

Admission

Formal acceptance as an inpatient by an institution, hospital or healthcare facility.

Admitting Physician

The physician responsible for admission of a patient to a hospital or other inpatient health facility.

Adverse Determination

A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not Medically Necessary.

Advisory Board of Osteopathic Specialists ABOS

American Osteopathic Association (AOA) certification agent organized in 1939 for the purpose of establishing and maintaining standards of osteopathic specialization and pattern of training.

Affordable Care Act

The health reform law signed into law by President Obama on March 23, 2010, is officially known as the Patient Protection and Affordable Care Act or PPACA. The law is also called the Affordable Care Act.

Allergy Treatment

The treatment of the allergic patient may include identifying the offending agent by means of various testing methods. Once the agent is identified, treatment is provided by avoidance, medication, or immunotherapy.

Allowed Charge

The Allowed Charge is the amount EmblemHealth will reimburse you for covered services rendered by non-participating Providers.

Ambulatory Care

All types of health services that are provided on an outpatient basis.

Ambulatory Care Facility

A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery and outpatient care in a centralized facility.

Ambulatory Surgery

Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.

American Board of Medical Specialties ABMS

Organized originally in 1933 as the Advisory Board of Medical Specialties, the ABMS (1970), in collaboration with the American Medical Association (AMA), is the recognized certifying agent for establishing and maintaining standards of medical specialization and pattern of training.

Ancillary Services

Auxiliary or supplemental services (i.e. diagnostic services, physical therapy, medications) used to support diagnosis and treatment of a patient's condition.

Annual Maximum

The maximum accumulated payments EmblemHealth will make for covered services rendered to a covered person during a calendar year, or the maximum number of covered days/visits available to a covered person for a particular service or services during a calendar year.

Appeal(s)

A process used by a provider or member to request the health plan reconsider a previous adverse determination.

Assignment

An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private insurance program for the service the patient has received.

Attending Physician

Physician primarily responsible for the care of a patient during hospitalization.

Authorization or Authorized

Services which have been approved for payment based on a review of EmblemHealth's policies.

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